Concussions: More Than a Smack Upside the Head

On May 21st 2012, Hall of Fame running back Eric Dickerson became the latest former superstar to sue the NFL over concussions. Currently, there are now 81 concussion-related lawsuits filed against the NFL, which include more than 2,240 former players. The contention of these lawsuits is that the league failed to adequately warn players that multiple head injuries can cause second-impact syndrome or chronic traumatic encephalopathy. CTE can permanently damage athletes' brains, resulting in memory losses, concentration lapses, speech troubles, bursts of anger, bouts of depression, and unusually early symptoms of Alzheimer's and other diseases.

Although the recent news flurries about concussions have centered around the NFL after the suicide of Junior Seau on May 2nd, the vast majority of concussion victims are ordinary citizens. Actually, the number one cause of sports-related head injuries is bike riding. Although concussions are most often associated with athletes, law enforcement officers are certainly not immune to concussions and/or chronic traumatic encephalopathy in the line of duty or in training. Take the example of Norfolk Police recruit John Kohn. According to reports, Kohn was first punched in the face by a police trainer during training; he reported the incident to his wife and classmates, complaining of a headache. Two days later he sustained additional head blows by another student and the instructor during a ground fighting session until he blacked out. Paramedics responded and he was flown to a hospital where he underwent brain surgery. He remained in critical condition until he was taken off life support on December 18th, 2010. Doctors determined that the cause of death was due to multiple brain injuries (second-impact syndrome). Whether he had reported his injuries to his superiors is under debate (and key to a pending lawsuit by his widowed wife).

The Norfolk Police have made changes in their training; they now ban intentional head strikes and require additional training for instructors and recruits in identifying and reporting possible injuries. The NFL has also repeatedly made changes related to their head injury protocol. But is it enough? How much damage has already been done? Do you know enough about concussions; not only as a LEO, but as a weekend warrior? What about chronic traumatic encephalopathy?

Concussion Overview

The purpose of the head is to protect the brain against injury. The brain weighs about three pounds, has the consistency of gelatin, and floats in cerebrospinal fluid which cushions the brain from normal daily activities. Force to the head may result in the brain bouncing violently against the inner wall of the skull causing bleeding in the spaces surrounding the brain, bruising of the brain tissue, or damage to the nerve connections. This results in a traumatic brain injury (TBI). Concussions have historically been referred to as a mild TBI (compared to gunshots to the head). However, there is nothing minor about a brain that has been concussed. Research suggests that 10% of all people who experience a single concussion have life-changing symptoms. Concussions are usually caused by a blow to the head, but they can also occur when the head and upper body are violently shaken (shaken baby syndrome). Concussions can cause loss of consciousness; however, often they do not.

Concussions are common injuries and usually resolve spontaneously. Most people recover fully. In fact, many people who have had concussions never realized it. However, every concussion injures your brain to some extent. The brain’s functions may be altered even if there is no structural damage to the organ. The effects of a concussion are usually temporary.

Signs, Symptoms, Diagnosis, and Treatment

The signs and symptoms of a concussion include: headache, dizziness, nausea, vomiting, feeling dazed, irritability, visual disturbances, ringing in the ears, confusion, slurred speech, amnesia, fatigue, depression and problems with concentration, memory, judgment, balance and coordination. Symptoms may be immediate or may be delayed. Symptoms usually disappear entirely within three weeks.

The CDC reports that there are about 1.7 million traumatic brain injuries treated in ERs or admitted to hospitals annually. About 90% of TBIs that occur each year are concussions. Of those people, about 80% percent recover from the concussion within three months. However, these statistics cannot be considered accurate as concussions are notoriously under-reported and untreated.

The diagnosis for a concussion is based on a good history and presenting symptoms. Concussions are considered invisible injuries. There is no test to confirm a diagnosis; neither a MRI nor a CT scan can accurately detect a concussion. However, brain imaging may be used to determine whether the injury is more severe and has caused significant bleeding or swelling in the skull.

Rest, time and monitoring are really the only current treatments for a concussion. Rest needs to be both physical and mental to allow the brain to recover. This means the subject must avoid general exertion as well as activities that require mental concentration (playing video games, watching TV, texting, smart phones, computers, etc). Workloads should also be temporarily reduced or suspended. Concussions can take days or years to heal. Additional care is required to prevent repeated concussions. These concussions can cause cumulative brain damage such as second-impact syndrome or chronic traumatic encephalopathy. For unknown reasons, having had one concussion significantly increases a person's risk of having another.

However, there is new treatment hope on the horizon. Clinical trials have initially demonstrated that the female hormone progesterone might protect against neurological damage of a concussion if administered within the first few hours following a traumatic brain injury or stroke. Studies, first performed at Emory University, found no side effects from this treatment. Participants who had received progesterone after a TBI were 1/2 as likely to die, and if their concussions were moderate, they were significantly less disabled.

Second-Impact Syndrome

Second-impact syndrome develops in people who receive a second head injury minutes, days or weeks after an initial concussion, before its symptoms have resolved. The condition is often fatal, and almost everyone who is not killed is severely disabled.

Chronic Traumatic Encephalopathy (CTE)

The result of multiple concussions frequently results in chronic traumatic encephalopathy. The outward symptoms of chronic traumatic encephalopathy are very similar to the symptoms of Alzheimer's disease and other dementias: memory problems, disorientation, and difficulty concentrating are the earliest signs. As the disorder progresses, additional symptoms occur: poor judgment, erratic behavior, significant memory loss, and some degree of Parkinson's disease (impaired speech, difficulty with motor skills, slow movement and a loss of balance). In more advanced stages of CTE, individuals suffer with tremors, full-blown Parkinsonism, a staggering gait, deafness and dementia. Chronic traumatic encephalopathy also causes significant psychological problems: depression, agitation, aggression, violence, loss of inhibitions, sexual compulsiveness, euphoria, drug/alcohol abuse, and suicide. There is no specific treatment for CTE.

Tips for Law Enforcement Officers and Supervisors

Law enforcement officers can sustain a concussion under a variety of scenarios other than during training with an overzealous trainer. Imagine yourself chasing Joe B. Badguy on foot, you grab him and you both tumble to the sidewalk, hitting your head on the concrete… Or, the code 3 call that results in a traffic accident…Motor and bicycle patrol officers are at even greater value. What about an assault by a suspect carrying hidden brass knuckles (or any other of a variety of weapons)… Concussions happen. The best advice is to arm yourself with knowledge before a concussion happens.

Seek emergency care for anyone who experiences a head injury and has: a loss of consciousness lasting more than a minute; repeated vomiting; seizures; unequal pupils; obvious difficulty with mental function or physical coordination.

Know the signs and symptoms of a concussion and report your injuries to your supervisors. If you have had your “bell rung” you have had a concussion.

Recognize subtle hints that a peer may have experienced a concussion after any head trauma. Take a detailed history of the event and the subject’s complaints.

A concussion is not always a medical emergency. However, the CDC reports that people with a concussion should be seen by a health care professional. This is especially important in the very young and the elderly who may not be able to verbalize their symptoms. At least a call to your health provider is in order.

If an individual does not seek emergency care he/she needs to be monitored by someone for 12-24 hours to observe for changes in brain functioning, arousal, consciousness.

Bleeding can occur under the scalp at the site of the head injury resulting in a hematoma (commonly referred to as a "goose egg"). To decrease this swelling ice may applied for 20-30 minutes about every two to four hours for up to 48 hours.

No one should return to any vigorous activity, which may include work, while signs or symptoms of a concussion are present; usually 7-10 days.

Training officers need to punch without causing head injury.

There must be no stigma attached with any head injury, no matter how superficial it may seem on the surface.

After a concussion only take acetaminophen (Tylenol) for headache. Aspirin or ibuprofen may increase the risk of bleeding.

Avoid medicines or substances that cause drowsiness or changes in level of consciousness: narcotic pain medicines, alcohol, sleeping aids, muscle relaxants, or tranquilizers--the symptoms produced by all of these drugs are similar to those of increasing pressure within the brain, and may mask important symptoms of a worsening condition.

Practice and teach safety and injury prevention: Wear appropriate protective gear that fits properly, is well maintained, and worn correctly. Always buckle your seat belt, make sure airbags are functional. Keep your home and work place safe. However, be aware, there is no protective gear that can significantly prevent concussions from occurring. Helmets are designed to protect against high-impact collisions that could crack the skull, they do not have the design or technology to prevent concussions.

Pamela Kulbarsh, RN, BSW has been a psychiatric nurse for over 25 years. She has worked with law enforcement in crisis intervention for the past ten years. She has worked in patrol with officers and deputies as a member of San Diego's Psychiatric Emergency Response Team (PERT) and at the Pima County Detention Center in Tucson. Pam has been a frequent guest speaker related to psychiatric emergencies and has published articles in both law enforcement and nursing magazines.